Time to turn Cleaning Staff into Certified Technicians

Hospital corridor


Healthcare-associated infections claim thousands of lives and cost the healthcare system billions of dollars annually. While the proper cleaning and disinfection of the physical environment is considered to play a major role in combating the spread of infectious disease, the front-line workers charged with this role remain the lowest paid and least educated worker group in the hospital. The time has come to turn cleaning professionals into Certified Environmental Services Technicians or CEST. Moreover, infection prevention will only become a reality when the CEST is properly regarded, educated and equipped.

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Simple cleaning of the environmental surfaces may be one of the key defenses in the future battle against infectious disease. With antibiotic-resistant organisms proliferating on common touch-points for up to 56 or more days, the study of cleaning and measuring cleanliness is becoming all-important.

What is the cost of not providing a safe, clean environment? It could be millions of dollars and a loss of confidence by the community a hospital serves. A court awarded $13.5 million to the family of a patient who died of flesh-eating bacteria that she contracted during chemotherapy treatment in a facility. In a separate case, a patient was awarded $2.58 million because he contracted MRSA (Methicillin-resistant Staphylococcus aureus) in a hospital. Although cleaning and hygiene issues may not always be the subject of dramatic litigation, there is little doubt that poorly cleaned facilities are contributing factors to serious disease transmission.

The Burden of HAIs

In the United States, hospitals are in the business of providing healthcare to over 35 million inpatients and performing over 51 million procedures annually.1 The Centers for Disease Control and Prevention (CDC) estimates that 5-10% of patients get a hospital-associated infection (HAI) or nosocomial infection during their stay.2 This staggering statistic shows just how critically important it is that everyone, from hospital executives down to front-line workers, understands the need for a coordinated, multimodal effort in controlling and preventing the spread of infectious diseases.

The impact of HAIs includes prolonged hospital stays, long-term disability, increased resistance of microorganism to antimicrobials, a massive additional financial burden for health systems, high cost for patients and their families, and excess deaths.

In the U.S., it is estimated that an HAI could potentially add 19 days to the average 4.8 day length of stay in hospital,5 leading to direct and indirect societal costs totaling $96-$147 billion annually.6 In Europe, HAIs cause 16 million extra-days of hospital stay, 37,000 attributable deaths, and contribute to an additional 110,000 deaths every year10. Likewise, in Canada more than 220,000 healthcare associated infections result in 8,500-12,000 deaths each year11.

The Role of Environmental Service Workers

Environmental service workers play an essential role in prevention of HAIs. Recent studies have demonstrated significant improvements in cleaning through interventions directed at environmental service workers.7-9 For optimal effectiveness, such interventions require that environmental service workers be knowledgeable about the prevention and transmission of disease and well trained with the best practices that keep patients safe.

“Compliant cleaning and disinfection of environmental surfaces and medical equipment is a critical first line of defense against all pathogens in the healthcare environment, and especially those that are resistant to antibiotics,” Sarah, C. Bell-West, PhD, senior scientist at Clorox Healthcare.

At a time when pharmaceutical companies are slow to develop new antibiotics to defeat MDROs (Multidrug-Resistant Organisms), Steven Ashkin, president of the Ashkin Group remarks, “This redirection means more emphasis will be placed on preventing illness, and that’s where effective and environmentally responsible cleaning comes in. In other words, our industry is being called upon to step in and help stop the spread of disease at a time when the pharmaceuticals are stepping out. Increased investment in training, equipment, and health-protecting cleaning methods is already helping us accomplish this.”

This is a message that needs more communication at the senior levels of hospital leadership, but I know from personal experience that the Environmental Services Department rarely appears on the radar of hospital administrators, except when there is a need for budget cuts.

Many hospitals have found housekeeping an easy means of budget cutting, leaving housekeepers to simply dump the trash and move on to the next room

“Many hospitals have found housekeeping an easy means of budget cutting, leaving housekeepers to simply dump the trash and move on to the next room,” reported a 2012 survey of environmental services managers by UMF Corp. The survey, in the report “Doing Everything: Multimodal Intervention to Prevent Healthcare-Associated Infections,” found that environmental services departments are, on average, short by five to nine full-time employees, “despite hospital expansions, expanded services, increased patient admissions and shorter lengths of stay (which creates more room turnover).”

When hospitals want to compete in their market, leaders often look to buying the latest 128-slice, 3D CT scanner or Divinci robot to perform surgeries, recruiting the best surgeon, or beginning a new service line with the best return on investment. While these capital expenditures and improvements might attract publicity for a fleeting moment, the Board of Directors needs to consider a different, low cost option that provides the best chance to improve patient satisfaction, reduce HAIs and improve the bottom line: the Environmental Services Department.

The literature is replete with articles and studies in infection prevention annals extolling the virtues of various environmental hygiene Products, Processes and Programs to reduce HAIs in healthcare. The one missing “P” is the People who work hard, do a dirty (sometimes disgusting) and repetitive job, and earn the lowest wage in the hospital, while tasked with providing a safe, clean and disinfected environment for patients and staff; the People of the Environmental Services Department.

In an article titled, “Clean Sweep: Hospitals Bring Janitors to the Front Lines of Infection Control” (Scientific American, 2012), Maryn McKenna wrote,  “Just a few years ago the poster bug for nasty bacteria that attack patients in hospitals was MRSA. Because MRSA clings to the skin, the chief strategy for limiting its spread was thorough hand washing. Now, however, the most dangerous bacteria are the ones that survive on inorganic surfaces such as keyboards, bed rails and privacy curtains. To get rid of these germs, hospitals must rely on the staff members who know every nook and cranny in each room, as well as which cleaning products contain which chemical compounds.”

The Case for Educating and Certifying Cleaning Professionals

Given the importance of providing a clean, disinfected environment, doesn’t it make sense to educate and certify environmental services workers so they understand that better, more thorough cleaning and disinfection saves lives?

Unlike many European countries, there are no education requirements or necessary certifications for cleaning professionals in the United States. In my opinion, the reason for the “low expectations” for education requirements and certification of ES workers is that hospitals want to keep the wage rates low. Once you start attaching certifications to any profession, it requires that certified workers are paid more.

the least educated and lowest paid people in the hospital must eliminate those dangerous bacteria

The U.S. Bureau of Labor Statistics found the median pay for janitors and building cleaners to be just more than US $22,000 per year and $10.73 per hour. When it comes to keeping pathogenic organisms at a safe level on environmental surfaces, the least educated and lowest paid people in the hospital must eliminate those dangerous bacteria. “This is the level in the hospital hierarchy where you have the least investment, the least status and the least respect,” says Jan Patterson, MD, past president of the Society for Healthcare Epidemiology of America (SHEA).

Hospitals have consistently held a low regard for the housekeeping department. Too often, housekeepers or environmental service workers are thought to be expendable (anyone knows how to clean a toilet and mop a floor, right?) and difficult to educate because English may not be their first language. The thought is, “What if I educate and certify them and they leave?” But, worse than that, what if you don’t educate and certify them and they stay?

Learning Objectives for the CEST

The stakes are too high to allow the rooms of residents or patients to be cleaned by a person who is not a CEST. The CEST must be properly compensated, regarded as a part of the facility’s multimodal infection prevention program, be well trained in the nuances of cleaning and disinfection, allotted the time to do the necessary tasks, equipped with the “Best in Class” tools to clean and disinfect surfaces and educated about the prevention and transmission of disease.

The learning objectives of CEST certification are:

  1. Define the Environmental Services worker’s primary role as infection prevention
  2. Equip the front line cleaning professional with knowledge of infection prevention as it relates to their daily tasks
  3. Analyze the cleaning professional’s role in patient satisfaction
  4. Support the cleaning professional with practical “how to” tips for cleaning and disinfecting
  5. Introduce cleaning and disinfecting strategies that effectively break the chain of infection
  6. Convert the cleaning professional into a Certified Environmental Services Technician

The cost of education would be between $100 and $500 per employee, with an additional fee for third-party testing and certification. The pay of the Certified Environmental Services Technician should be similar to that of other para-professionals in healthcare. ‘Paraprofessional’ is a job title given to persons in various occupational fields, such as education, healthcare, engineering and law, who are trained to assist professionals but do not themselves have professional licensure. Depending on the cost of living for a city, the hourly rate could be $15-30 an hour.

An educated and certified environmental services technician will be viewed as a knowledgeable professional, working amongst other healthcare professionals, who are certified or registered in their own area of expertise. Knowledge leads the environmental services worker to be proud of the profession they have chosen and respected by their colleagues and patients.

I will conclude with one closing thought: One well-trained, well-equipped, conscientious Certified Environmental Services Technician, given the proper tools and an adequate amount of time to clean and disinfect a room patient’s room, can PREVENT more infections than a room full of doctors can CURE.


  1. Centers for Disease Control and Prevention, Hospital Utilization (in non-Federal short stay hospitals), Hospital Inpatient Care-Number of Discharges; Procedures Performed, May 14, 2015; http://www. cdc.gov/nchs/fastats/hospital.htm
  2. Centers for Disease Control and Prevention, “CDC at Work-Preventing Healthcare-Associated Infections”; http://www.cdc.gov/washington/~cdcatWork/pdf/infections.pdf
  3. Safe Patient Project, “Health Care Worker Hand-Washing Compliance Remains Frustratingly Low”, June 13, 2013; http://www.safepatientproject.org/posts/4569-health-care-worker-hand-washing-compliance-remains-frustratingly-low
  4. Centers for Disease Control and Prevention, Nursing Homes and Assisted Living (Long Term Care Facilities [LTCFs]), January 27, 2015; http://www.cdc.gov/longtermcare/
  5. AHRQ-Agency for Healthcare Research and Quality, “Health Care-Associated Infections Greatly Increase the Cost of Hospital Stays”, AHRQ News and Numbers, August 25, 2010; http://archive.ahrq.gov/news/newsroom/news-and-numbers/082510.html
  6. Pub Med, National Center for Biotechnology Information, “Economic Burden of Hospital-Acquired Infections in US Acute Care Hospitals: Societal Perspective”, October 18, 2013; http://www.ncbi.nlm. nih.gov/pubmed/2402498
  7. Carling PC, Parry MF, Von Beheren SM. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol 2008:29:1-7
  8. Carling PC, Parry MM, Rupp ME, Po JL, Dick B, Von Beheren SM. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol 2008:29:1035-41
  9. Carling PC, Parry MF, Bruno-Murtha LA, Dick B. Improving environmental hygiene in 27 intensive care units to decrease multidrug-resistant bacterial transmission. Crit Care Med 2010:38:1054-9
  10. The Joint Commission (2012, May). Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources. http://www.PreventingCLABSIs.pdf.
  11. Zoutman DE, Ford BD, Bryce E, et al. (2003). The state of infection surveillance and control in Canadian acute care hospitals. American Journal of Infection Control, 31(5). 266-72.


  1. Darrel as usual has hit on many of the key issues that need attention to turn the tide on Infection Control. Whilst what Darrel is proposing here makes sense from the perspective of saving human suffering and lives, it requires an entire “culture change” within the health care sector.

    When the Sarbanes Oxley financial reform act was passed, the very beginning of the legislation referred to “The Tone From The Top”; in other words it is the approach and perspective of the very senior management of an organization that determines its culture and core behavioural patterns. As the famous management consultant stated, “Culture eats Strategy for Breakfast” when it comes to determining the direction and ways an organization functions.

    So the false economies of cutting housekeeping / janitorial costs, mainly through personnel, combined with often unnecessary expenditures on technology within the healthcare sector represents a cultural mindset that is all too pervasive across the industry. Changing this is going to be the challenge.

    And so its a classic “chicken and the egg” issue; education equates to change. But it seems its a matter of needing to educate the industry leaders first to get the necessary change in Culture that will facilitate the initiatives that Darrel sets forth here. And in acknowledging this issue, the problem of the conflicts of interest within the US Healthcare System come to the very fore; in publically traded healthcare providers, from hospitals to insurance companies, there is a conflict of interest at several levels:

    (1) Jack Welch changed global corporate culture in his famous (or infamous) speech in the mid 70s when he stated that the only role and objective of any CEO was to maximize returns for shareholders. That statement has become the “mantra” for the for “C Level” execs across the globe, and now where more so than the publically traded US healthcare companies. As such there is a core conflict of interest between maximizing returns for shareholders and providing the best services and value to customers.

    (2) Given most senior execs at leading healthcare companies in the US (insurance and healthcare facilities)get a majority of the remuneration in stock options, this conflict of interest is at the very heart of the determination of the “Tone at the Top” of these organizations and so sets the Corporate Culture.

    So these conflicts of interest are what need to be addressed so as to generate the necessary change in Culture to enable the very strategy that Darrel has laid out here to become the much needed reality in our Health System.